Bladder Lesion in a Older Female

Specimen Type:

Bladder

History:

A 56-year-old woman who had a history of ano-rectal squamous cell carcinoma underwent a pelvic exenteration which included the rectum, uterus, and urinary bladder. Grossly, in the posterior wall of the bladder there is a 3.3 x 2.2 cm ulcerated area, and cut sections through this area show an indurated muscle wall with a glistensing, slightly mucoid cut surface. Submitted are representative sections from this ulcerated area of bladder as well as sections from uterus, rectum, and perivesical lymph nodes.

Pathologic Features:

Bladder sections reveal scattered single and clusters of glandular structures throughout the bladder wall (Figs 1, 2). The glands are lined by epithelium of various types including cuboidal, tall columnar, ciliated, and mucinous (Figs 3, 4, 5, 6). Transition from cuboidal ciliated to columnar mucinous epithelium is also noted (Fig 7). Hemorrhage and hemosiderin deposit are present in the adjacent stroma around the glands (Fig 8). Sections from perivesical lymph nodes and rectum demonstrate similar glandular structures (Figs 9, 10, 11, 12). Similar glands are also found in the uterine wall. Glands in the bladder wall show nuclear staining for ER (Fig 13).

Differential Diagnosis:

  • Bladder: Florid cystitis glandularis with transmural involvement of bladder muscle wall
  • Bladder: Adenocarcinoma

Florid cystitis glandularis:Florid cystitis glandularis which is thought to arise from Brunn’s nests is uncommon. In the lamina propria, there are numerous glands lined by cuboidal to columnar cells. Usually, cystitis cystica lined by urothelium is also noted nearby. This lesion is distinguished from adenocarcinoma by the lack of stromal infiltration and marked cytologic abnormalities. Cases in which there are distorted glands in the stroma, deep within the lamina propria or even in the muscularis propria, particularly with cytologic abnormalities, should be evaluated carefully to exclude malignancy (Fig 14).

Adenocarcinoma: Primary adenocarcinoma of the bladder accounts for less than 1% of bladder cancers. Intestinal metaplasia can coexist in up to 67% of patients. The histologic patterns include colonic, mucinous and so forth. Infiltrating the muscle wall and marked cytologic abnormalities are diagnostic features. Figure 15. HE 200X: Colonic pattern of adenocarcinoma arising in the bladder (Fig 15).

Diagnosis:

Müllerianosis involving bladder wall, rectum and lymph nodes

Key Features:

  • A combination of a variety of müllerian-type epithelium including endometrial, endocervical (columnar mucinous cells), and tubal (ciliated cells, peg cells, and intercalated cells)
  • Bland cytologic features
  • Immunostain for ER/PR is useful to identify the nature of hormonal-sensitive epithelium

Comment: Müllerianosis of the urinary bladder is a very rare and morphologically complex tumor-like lesion (references 1, 2). It is composed of several types of mullerian-type lesions, including endometriosis, endocervicosis, and endosalpingiosis. This disease occurs in women of the reproductive age group. In the pathogenesis, implantative and metaplastic origins have been suggested, and they are still under discussion. A rare case in a 41-year-old woman was described in which in addition to typical müllerianosis, cystitis glandularis with focal intestinal metaplasia was found, and a continuity between the glands of mullerianosis and glands of glandular cystitis was also noted. Müllerianosis with lymph node involvement is also identified in this case, which is extremely rare (references 3, 4).

Müllerianosis can be distinguished from adenocarcinoma and various non-neoplastic glandular lesions of the urinary bladder on the basis of architectural and cytologic features.

The treatment of mullerianosis of the bladder includes hormonal manipulation and resection.

References:

  1. Young RH, Clement PB. Mullerianosis of the urinary bladder. Mod Pathol. 1996 Jul; 9(7):731-7.
  2. Koren J, Mensikova J, Mukensnabl P, Zamecnik M. Mullerianosis of the urinary bladder: report of a case with suggested metaplastic origin. Virchows Arch. 2006, 449 (2):268-71.
  3. Insabato L, Pettinato G. Endometriosis of the bowel with lymph node involvement. A report of three cases and review of the literature. Pathol Res Pract. 1996;192(9):957-61; discussion 962.
  4. Lorente Poyatos R, Palacios Perez A, et al. Rectosigmoid endometriosis with lymph node involvement. Gastroenterol Hepatol. 2003 Jan;26(1):23-5.